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Pediatric Emergencies

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Dalacey Traeger

on 7 March 2014

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Transcript of Pediatric Emergencies

Child Abuse and Neglect
Child abuse can consist of neglect as well as physical, sexual, or emotional abuse.
More than 2 million cases reported annually.
What to look for:
The Death
of a Child

Growth and Development
Neonate: Birth- 1 month
Infant: 1 month- 12 months
Toddler: 12 months- 24 months
Preschool Age: 3-6 years
School Age 6-12 years
Adolescent 12-18 years
Pediatric Emergencies
Family may want you to resuscitate, even if child is clearly deceased
Find a place where the family may watch resuscitation without being in the way
Do not speculate on cause of death
When the decision to stop resuscitation is made, inform the family immediately
Ask if they would like to hold the child and say goodbye.
Acknowledge the family’s feelings
Ask if they are part of a faith community, if there is anyone they want you to call, etc.
Death of a child can be traumatic for EMS providers as well.
Be alert for signs of PTSD is yourself and your coworkers
It can be helpful to take some time to work through your feelings before returning to work.
Infants

Sleep up to 16 hrs/ day
Predisposed to hypothermia
Well-developed hearing
Communicate by crying
Cannot distinguish between family and strangers

Begin to smile
Make eye contact
70 % can sleep through the night
Anterior fontanelle closes at 6 months

Learn to sit up, crawl, and walk
Begin to babble
Risk of foreign object aspiration increases

Assess from a distance as possible
Provide sensory comfort
Save painful procedures for last
V.S. Newborn: R:30-60, Sys BP: 50-70. Infant: R: 25-50, P: 100-160, Sys BP: 70-95
Toddlers
Begin to walk and explore
Learn a few words
Foreign body aspiration is huge concern
Posterior fontanelle closes at 18 months
Separation anxiety peaks at 18 months
May dislike being restrained
Easily distracted
V.S. R: 20-30, P: 90-150, Sys BP: 80-100
Preschool Age Children
3-6 Years
Master toilet training
Have a rich fantasy life
Learning appropriate vs. inappropriate behavior
Risk of foreign body aspiration remains high
0-2 Months
2-6 Months
6-12 Months
Assessment
Assessment
Can follow directions, describe and localize pain
Distract them with games, toys, etc
Always be honest. Lost trust is difficult to regain.
V.S. R: 20-25, P: 80-140, Sys BP: 80-100
School Aged Children
6-12 Years
Are able to think concretely, answer questions, and help take care of themselves.
Begin to understand that death is final
Concerned about fitting in with their peers
Assessment
Assessment
12-18 Months
18-24 Months
Rapidly Expanding Vocabulary
Begin to understand cause and effect
Learn to run and climb
Talk to the child
Offer choices, but control the possible outcome
Provide simple explanations for their pain
Reward their cooperation
V.S.: R: 15-20, P: 70-120, Sys BP: 80-110
The Pediatric Respiratory System
A Reminder...
Respiratory problems are the leading cause of cardiopulmonary arrest in children, so you should be constantly assessing your patient for signs of respiratory distress
Anatomical Differences:
Larger occiput, requires careful positioning to open airway.
Larger tongue which can easily obstruct the airway
Longer, floppy epiglottis
Less developed rings of cartilage in the trachea
The airway of children is funnel-shaped, rather than cylindrical
Respiratory Emergencies: Medical
Asthma
Bronchiole inflammation and excessive mucus production.
Extremely common- Almost 5 million children affected in U.S.
Treatment:
Be calm and reassuring, do not excite the patient
Administer supplemental Oxygen
Administer bronchodialator via MDI or nebulizer
Allow patient to assume position of comfort
Asthma that doesn't respond to treatment = status asthmaticus
Pneumonia
Leading cause of death in children worldwide
Can occur as a secondary infection, result of near drowning, or chemical ingestion
S/S: Tachypnea, crackles, grunting, wheezing, fever or hypothermia, unilaterally diminished breath sounds
Treatment: Monitor airway and breathing, provide supplemental oxygen, transport promptly
Bronchiolitis
Occurs in first two years
Usually caused by respiratory syncytial virus (RSV)
More common in males, most common in winter and early spring.
S/S: dehydration symptoms, shortness of breath, fever
Treatment: Position of comfort, humidified oxygen if possible, monitor airway
Respiratory Emergencies: Trauma
Airway Obstructions
Extremely common in children <5 yrs.
S/S of upper airway obstruction: decreased or absent breath sounds, stridor
S/S of lower airway obstruction: wheezing and crackles
Treatment:
If patient is still coughing/making sounds, do not intervene, except to provide supplemental oxygen and encouragement
If you see S/S of a severe obstuction, such as cyanosis, loss of consciousness, inability to cry or cough:
Open airway, and if visible, remove obstruction
If not, provide chest compressions or chest thrusts and back slaps
Drowning Emergencies
2nd most common cause of unintentional death among kids in US
Children under 5 years of age are especially are risk
Treatment: Once the patient is removed from the water, assess and manage ABCs, provide CPR if needed, contact ALS, provide oxygen or ventilations if needed, if trauma is suspected, take spinal precautions
The Pediatric Circulatory System
Shock in Pediatric Patients
Though pediatric patients have a greater proportional blood volume than adults, shock can result from as little as one cup of blood loss.
Children are especially good at using vasoconstriction to compensate for blood loss, so they may be in shock while displaying a normal blood pressure
Signs of hypoperfusion in children are pale skin, weak distal pulses and capillary refill >2 seconds
The Pediatric Nervous System
Anatomical Differences
The pediatric nervous system is underdeveloped, immature and poorly protected, compared to adults.
Infants and toddlers are especially prone to head injuries due to their large heads and poorly protected brains.
Pediatric brain at higher risk for brain damage from hypoglycemia or hypoxia, due to their high need for glucose and oxygen.
Spinal cord injuries are relatively uncommon
Reviewing AMS
Remember that there are several possible causes of altered mental status
A helpful mneumonic is AEIOU-TIPPS- Alcohol, Epilepsy/Endocrine/Electrolytes, Insulin, Opiates and Other drugs, Uremia, Trauma/Temperature, Infection, Psychogenic, Poison, Shock/Stroke/Space-Occupying lesion/Subarachnoid hemorrhage
S/S of AMS in younger pediatric patients may include: sleepy or lethargic appearance, combativeness, or lack of response to tactile stimulation
Neurological Emergencies: Medical
Meningitis
High-risk populations: males, newborns, immuno-compromised patients, children with head trauma and children with shunts, pins or other foreign bodies in the CNS, and those living in close, crowded living situations such as college dorms
S/S: Fever, altered LOC, confusion, headache, pain to bend neck forward and backward, bulging fontanelle with no crying
Infants <3 months may display apnea, cyanosis, fever, a distinct high pitched cry, or hypothermia
Neisseria meningitidis is a dangerous form of meningitis that progresses very rapidly. This form of meningitis may present with small, pinpoint cherry-red spots, or a larger purple/black rash.
Meningitis is highly contagious and infectious!- Protect yourself!
Treatment for these patients includes supplemental oxygen and ventilations if needed.
Seizures
In infants, seizure manifestation may consist of an abnormal gaze, sucking motions or "bicycling" motions
Your priority is securing and protecting the airway and providing supplemental oxygen however you can.
If the patient is in status epilepticus, call for ALS backup
Febrile Seizures
This type of seizure is most common in children 6 months- 6 years of age
They generally last <15 minutes with a short postical state, none at all
Treatment: Assess and manage ABCs, begin cooling with tepid water, and transport.
Are able to think abstractly and make decisions
Personal morals develop
Begin to rely on friends for psychological support
Puberty begins
Become interested in romantic relationships
Risk-taking and experimentation; think they are invincible
Assessment
Respect the adolescent's privacy
Allow the patient to be involved in their care, but provide guidence
Protect their modesty. May need an EMT of the same gender
Be aware that pregnancy may be possible. Bring it up tactfully if pertinent.
V.S. R: 12-20, P: 60-100, Sys BP: 90-110
12- 18 Years
Adolescents
Neurological Emergencies: Trauma
Shaken Baby
Syndrome
Intentional, forceful shaking tears the fragile blood vessels in an infant's brain, causing bleeding within the brain
Call may be for an unresponsive infant who stopped breathing
Infant may appear to be in cardiac arrest; acutally, the bleeding has caused increased ICP, which leads to coma and death.
The Pediatric
Gastrointestinal System
Anatomical Differences
The G/I system is less developed and less protected in children than in adults
Children are more prone to injury and bleeding, especially of the spleen and liver
Abdominal complaints may be vauge in nature, but should never be taken lightly
Always monitor these patients closely for signs of shock
The pediatric population is sensitive to fluid loss, so it is important to get a thorough history to determine if the patient may be dehydrated.
Gastrointestinal
Emergencies
Appendicitis
Could result in peritonitis if left untreated
S/S: fever, pain in RLQ with rebound tenderness
If you suspect appendicitis, transport immediately so the patient can be further evaluated at the hospital
Dehydration
With any gastrointestinal complaint that involves vomiting and/or diarrhea, you should be alert for signs of dehydration
S/S of dehydration include: dry lips/gums, lack of tears, poor skin turgor, sunken fontanelles, few wet diapers
If dehydration is severe, you may need to call ALS to start an IV
Poisoning
S/S of a poisoning may vary depending on the substance which the patient was exposed to
After completeing your primary assessment, determine: What substance was involved? Approximately how much was ingested?What time did it occur?Changes in behavior or LOC? Was there any choking or coughing?
Treatment: External decontamination, if applicable, ABCs, evaluate and treat for shock, and administer activated charcoal if approved.
The Pediatric Integumentary System
Fever Emergencies
Many possible causes of fever
Be sure to obtain an accurate body temp
For infants and toddlers, rectal thermometers are most accurate
Older children can use oral thermometers
Monitor the patient for additional signs and symptoms to help determine what is causing it.
Anatomical
Differences
Skin is thinner and less insulated than adults
Children are especially prone to heat loss
Children's skin burns much more easily than adults
Remember that infants <6 months old cannot shiver to generate body heat.
However, you can reduce heat loss by as much as 50%, simply by covering the head
Trauma in Pediatric
Patients
Trauma is the #1 killer of children in the US!
Anatomical
Differences
Bones are softer and more flexible in children
The younger the child, the more flexible it is to trauma
Active growth plates at the ends of long bones are weak spots, and are injured frequently, which can result in length discrepancies
Children will be hurt in different places than adults in similar situations, due to their smaller size
Burns
More serious in children than adults because they have more surface area relative to total mass
Shock, hypothermia and airway problems are more likely in kids
Use sterile techniques to avoid infection
Consider possibility of child abuse
Injuries to Specific Body Systems
Head Injuries
Very common, due to children's large heads
If your patient has nausea or vomiting after a traumatic event, you should highly suspect a head injury
Management of head injuries in children is the same as adults
Chest Injuries
Are usually the result of blunt trauma in Peds
Because of children's soft, flexible ribcages, high energy trauma, such as a car accident, can easily produce a flail chest
Abdominal Injuries
Remember that pediatric patients compensate for blood loss especially well
Monitor children with abdominal injuries closely, be alert for signs of shock
Always maintain a high index of suspicion in children with abdominal injuries, even if they aren't displaying S/S of shock
Injuries to the
Extremities
Children are more likely to have incomplete or greenstick fractures because of their softer skeletal system
Spint all possible fractures, but be sure to use immobilization equipment that is the proper size
Pain
Management
Positioning
Ice packs
Elevation
A kind, reassuring, professional demeanor
Pediatric
Patient Assessment
Scene Size-up
Primary Assessment
Pediatric Assessment Triangle
Hands-on ABC assessment
Transport decision
History Taking
Secondary Assessment
Reassessment
Scene Size Up
On your way to the scene, you should prepare yourself mentally for treating an infant or child. Brushing up on your pediatric protocols and vital signs is also a good idea!
Scene size-up is essentially the same in Peds patients as in adults
But remember that as the patient's advocate, you should be alert to family-child interactions and the child's living conditions.
Primary
Assessment
The Pediatric Assessment Triangle
10-15 Second assessment
Allows you to quickly, non-invasively assess life threats in a pediatric patient
Consists of: Appearance, Work of Breathing, and Circulation to Skin
Based on these findings:
Stay and play, or load and go?
Hands-on
ABC Assessment
Airway
Position in neutral sniffing position by padding shoulders with towel
Use head-tilt chin-lift or jaw thrust as indicated
Breathing
Look, listen and feel, using both hands to feel for adequate, equal chest rise and fall
Look for signs of respiratory distress
Be prepared to ventilate if needed
Circulation
Pulse rate and quality (use the brachial artery in infants)
Skin color and temp
Capillary refill < 2 sec?
Disability
LOC using either APVU or Pediatric GCS
Pupil reactivity and equality
symmetrical movement of extremitie
Exposure
Be sure to avoid heat loss by promptly covering your pt after
Transport
Decision
Load and go, or stay and play?
Transport immediately if MOI is significant, LOC is abnormal, there is a serious anatomical abnormality, etc...
Patients under 40 lbs should be transported in a car seat (their own, if possible), secured to the captains chair, unless:
They must be immobilized
They need a splint which will not fit in the car seat
They require ventilatory support
History Taking
Your Approach
Your approach to history taking will vary, depending on the age of your patient.
For infants and young children, you will be obtaining medical history from parents/caregivers
With older children and adolescents, you should speak to them directly
Remember to be tactful with sensitive questions such as possible pregnancy, drug use, etc..
Information to Obtain:
NOI or MOI
Onset
Events leading to injury or illness
Presence of fever
Effects on pts behavior
Pts activity level
Recent eating, drinking, bowel and bladder habits
Vomiting, diarrhea, abdominal pain
Rashes
SAMPLE
Secondary
Assessment
Physical
Examination
Full body scan when there is potential for hidden illnesses or injuries
Look for DCAP-BTLS
Focused assessment for pts without life-threatening illness or injury
Younger children should be assessed from the feet up, while school age children and adolescents can be assessed head-to-toe.
Vital Signs
Normal heart rates vary with age
Blood pressure is not usually assessed in kids <3 yrs.
Instead, assess skin color and temp
Make sure bp cuff fits properly
A simple formula to find the systolic lower limit: 70+ (2x child’s age in yrs)= Sys. BP
Reassessment
Reassess every 5 or 15 min. as indicated
If you are providing interventions, consider getting help from the parents or caregivers, which helps to calm and reassure the pt.
Document carefully and completely
Limit assessment to dressing any injuries
Do not examine genitals unless there is an injury that needs treatment
Do not allow child to wash, urinate or defecate before seeing a doctor.
Obtain as much information as possible
Shield and protect child from onlookers and bystanders
C- consistency of injury with child’s age
H- history inconsistent with injury
I- Inappropriate parental concerns
L- Lack of supervision
D- Delay in seeking care
A- affect
B- bruises of varying ages
U- Unusual injury patterns
S- Suspicious circumstances
E- Environmental clues
Bruises
Burns
Fractures
Neglect
Other
Indicators
Observe color and location
Bruises in various healing stages are suspicious
Bruises to back, face or bottocks are suspicious
Be suspicious of burns to genitals or buttocks
“Glove” burns or hands or feet
Cigarette burns or grid pattern burns
Femur and humerus fractures require major trauma
Falls from bed are not usually associated with fractures
Refusal or failure to provide life necessities
Children are often dirty, too thin, and may appear developmentally delayed
Child may be withdrawn, fearful or hostile
Conflicting stories
Refusal to discuss how an injury occured
Marked lack of concern from caregivers
EMTs are mandatory reporters
A Helpful Mnemonic:
Sexual Abuse
Sudden Infant
Death Syndrome
SIDS is the leading cause of death in infants <1 year
The cause is unknown, but there are several known risk factors, including low birth weight, tabacco use during pregnancy and mothers <20 y/o
3 major tasks for EMTs
Scene assessment- Observe general condition of the home, family interactions and how the infant was found
Patient assessment- SIDS is a diagnosis only after all other possibilities have been ruled out. If the infant shows postmortem changes (rigor mortis, etc), call medical control. Otherwise, start CPR
Communication and support of family- Use the infant's name when speaking to the family. When possible, allow the family to remain with the infant, and provide support in whatever way you can.
When infant resumes breathing and color with stimulation
Also called “near-miss SIDS”
Characterized by apnea, cyanosis, limp muscle tone, and choking or gagging.

Apparent
Life-threatening Event
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